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Dawn Mountz found her daughter 10 hours after she had run away from home. Huddled beneath playground equipment in a park, the 15-year-old cried and told the search party standing over her she wanted to die.

Then something changed. She froze.

“She actually became, it was so odd, almost like catatonic,” said 52-year-old Mountz, of Prineville. “Her hands were in fists, she was super stiff, staring out, pupils dilated.”

Just that morning, her daughter, who Mountz asked not be identified, had sat quietly in church beside her mother and younger sister. It was 2012. Mother’s Day.

When they got home, Mountz glanced out the window and saw her daughter, just about to turn 16, walking around in the backyard, which — even on a nice spring day — seemed odd. She went in the bedroom, changed out of her church clothes and put on jeans, and looked out the window again. Not even 10 minutes had passed. Her daughter was gone.

Police canvassed the small town all day, handing their cards out and letting people know what was going on.

Things hadn’t been right for a while, but never anything this extreme. Her daughter — adopted along with her biological sister from the Vladimir region of Russia eight years earlier — hadn’t been doing well in school. The information wasn’t clicking, and she was having memory issues. Suddenly, she couldn’t solve simple math problems.

After Mountz and a group of friends found Mountz’s daughter around 9 o’clock at night, they rushed her to the emergency room in Prineville, where she stayed for about three hours before being transferred to the larger hospital in Bend. She stayed there for three days, getting stable and receiving therapy from a psychiatrist who worked in the hospital at the time. Mountz hoped that was the end of it.

That summer, things only got worse. Mountz’s daughter talked regularly about wanting to kill herself. She dug sharp objects — nails, sharpened bobby pins, her fingernails — into her arms until they bled. She threatened family members. Even as all of this was going on, Mountz said, she couldn’t stand the thought of sending her daughter to Portland, where the state’s only acute pediatric psychiatric units are located.

By September, Mountz could no longer keep her daughter safe. She took her to Portland for a psychiatric evaluation. They said the teenager needed residential treatment, a step down from inpatient treatment that generally includes intensive individual and group therapy and monitoring by trained staff.

Mountz’s daughter spent the next seven months in two residential facilities across the state from her family.

When she was released in April, the staff recommended she enroll in day treatment, but since there are no facilities in Central Oregon that provide that treatment, she went straight to school instead. Day treatment provides community-based, individualized treatment to children and adolescents with psychiatric disorders who live at home but who wouldn’t be able to participate in traditional school or work settings.

Mountz’s experience of being sent hours away to get help for her daughter — and making do with minimal services once she finally brought her back home — is anything but unique for Central Oregon families whose children struggle with mental illness.

The past five decades have seen a trend toward shuttering large psychiatric facilities in favor of helping people within their own communities, a strategy many mental health professionals believe to be superior. The idea was to replace them with strong networks of outpatient services: providers, day programs, teams of community supports.

Unfortunately, the outpatient services largely failed to materialize and, in recent years, emergency departments, pediatricians, the criminal justice system and schools have become the main mental health providers for struggling children and adolescents.

{%ql-We’re unable to serve anywhere near the volume of kids and families who are referred to us. It’s a frustrating, worrisome experience. It’s really been this way for years, but it seems to be escalating.%em Ajit Jetmalani, Oregon Health & Science University%}

Now, providers in Central Oregon are at a breaking point. They’re scrambling to meet the crushing demand for pediatric psychiatric care while also trying to come together to pinpoint exactly what services are missing.

Meanwhile, state agencies are trying to figure out what must be done differently on a broad scale. At Oregon Health & Science University in Portland, calls from parents desperate to find their kids help have increased sharply over the past year, and kids seem to be more severely impacted than in the past, said Dr. Ajit Jetmalani, head of OHSU’s child and adolescent psychiatry division.

“We’re unable to serve anywhere near the volume of kids and families who are referred to us,” he said. “It’s a frustrating, worrisome experience. It’s really been this way for years, but it seems to be escalating.”

Many say the current system forces families into an “all or nothing” scenario. At one extreme, children and adolescents are hospitalized when their conditions deteriorate so much that they threaten to hurt themselves or others. At the other, the people aren’t considered severe enough and get next to no care.

“We’re forced into this box where the only thing we care about is kids shooting themselves or each other,” said Dr. Nathan Osborn, one of only a small handful of child and adolescent psychiatrists in Central Oregon. “We don’t fund day treatment centers; we don’t fund intensive care, wraparound services — we don’t keep those services available, which is really a political and social decision.”

People left adrift

The 1962 book “One Flew Over the Cuckoo’s Nest” — launched to pop culture fame when it was turned into a movie 13 years later — painted a disturbing portrait of mental institutions as dysfunctional places where people were overmedicated, abused and ultimately forgotten. It contributed to a general sense that institutionalization was the wrong way to care for people with mental illness, a philosophy that has proliferated over the years, taking hold not only in public opinion, but also in federal and state policies.

Many point to a 1963 federal law as the first time mental health spending was deliberately shifted away from institutions and toward services that would keep people in their communities. Between 1986 and 2009, nationwide spending on inpatient and residential mental health services decreased from 63 percent of total public and private spending on mental health care to 32 percent, according to the Substance Abuse and Mental Health Services Administration.

Barrett Flesh, the program manager for Deschutes County’s Child and Family Program, said it’s been a necessary shift, as separating kids who are struggling from their families tends to make things worse by aggravating attachment disorders — at the root of countless mental health struggles — and perpetuating stigmas that surround psychiatric hospitalization.

“The family is not really engaged when they’re institutionalized,” he said, “and they start to identify from a developmental level that there is something wrong with them.”

In 2003, the Oregon Legislature directed agencies to reform the way children received mental health treatment. Particularly, lawmakers wanted to improve outpatient services, such as access to pediatric psychiatrists, day treatment programs and counseling, so that kids suffering from mental illnesses could be treated in their homes and communities rather than in institutions. Five years later, the number of kids admitted to residential psychiatric facilities dropped 40 percent, according to the Oregon Health Authority.

The problem with that, experts in the field say, is that when society largely takes away one form of treatment, it must build in equal force an alternative treatment system. When it comes to outpatient services, that largely did not happen. 
Children and adolescents with mental illnesses are heading down the same road as their adult counterparts, who were largely diverted to jails and prisons when the necessary outpatient services didn’t follow the widespread closure of residential facilities, Jetmalani said.

“If we shut down residential programs, reduce the number of hospital beds, but we don’t actually increase the capacity or quality of our outpatient services, then we have basically left people adrift,” he said, “and we start to use the public safety, juvenile justice and prison systems as go-to strategies for people with mental illness and behavioral challenges.”

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Beautiful place, few providers

When patients walk into Dr. Nathan Osborn’s private psychiatric practice — located among a spattering of small offices in a quaint, tree-covered stretch of Bend — they don’t talk to a receptionist through a glass window. In fact, there is no receptionist. Patients walk into the tiny space and either sit on a couch outside the closed office door or Osborn beckons them right in.

“It’s not real glamorous,” said Obsorn, a child psychiatrist, sitting in one of two armchairs across from the couch in his office, a comfortable, rustic-looking room that feels more like a cabin on a lake.

Osborn, a former schoolteacher who changed course shortly into his career to go to medical school, assumes a grave facial expression when asked about the state of psychiatric services for kids in Central Oregon. He said his days are jammed with back-to-back sessions with kids and their families — evidenced by the family waiting outside during this meeting. In a medical industry more known for shunning competition, Osborn said he’d like to see 10 more child psychiatrists locally.

“You can only take one bite of an elephant sandwich at a time,” he said. “It can feel pretty overwhelming.”

Interviews with a number of local providers and families turned up only three child and adolescent psychiatrists in Central Oregon, one of whom — Dr. Gurpreet Chopra — also spends a portion of his time seeing adult patients. (It’s possible that other general psychiatrists see children, but only three have made it a substantial part of their practices.)

“It’s sort of baffling to have such an incredibly beautiful place and have such few child mental health providers,” Jetmalani said. “I’m very surprised that Bend has not done better than it has in attracting more providers.”

Psychiatrists have medical degrees and can prescribe psychiatric medications, as can pediatricians and nurse practitioners. Although there are several psychologists and therapists in Central Oregon, those providers cannot prescribe medications to patients.

Statewide, the Oregon Council of Child & Adolescent Psychiatry has 120 members, although not all of them have received training to work with children and adolescents.

Child and adolescent psychiatry is a specific sector of psychiatry that requires a two-year fellowship in addition to students’ post-medical school general psychiatry training, said Dr. Greg Fritz, president-elect of the American Academy of Child & Adolescent Psychiatry.

While there’s no law barring general psychiatrists from treating children, it’s important that they have the additional training, as mental illness shows up differently in kids compared with adults, and how that happens is heavily dependent on which stage of development they’re in, said Fritz, also the director of the Bradley Hasbro Children’s Research Center in Providence, Rhode Island.

Whereas adults generally are better able to articulate their complaints, children’s symptoms often show up as troublesome behaviors or physical symptoms, he said.

{%qr-A child who is depressed often does not say, ‘I’m sad,’ ‘I’m depressed’ or ‘I have trouble concentrating’ the way adults might. A child might say, ‘My belly hurts’ or ‘I’m bored.’%em Dr. Greg Fritz, American Academy of Child & Adolescent Psychiatry%}

“A child who is depressed often does not say, ‘I’m sad,’ ‘I’m depressed’ or ‘I have trouble concentrating’ the way adults might,” Fritz said. “A child might say, ‘My belly hurts’ or ‘I’m bored.’”

Chopra, who splits his time between a private practice out of the Bend Psychiatric Offices near downtown and at St. Charles Health System, said the first thing he tries to identify in pediatric patients is what developmental challenge they’re going through. Illnesses such as depression or anxiety, which are seen as chronic in adults, are often the product of a stalled phase in a child’s development, he said.

“When a kid is not growing toward the light, they can exhibit dysfunction in different ways,” Chopra said.

St. Charles Health System has been trying unsuccessfully to recruit two pediatric psychiatrists, but no one wants to practice in a community that doesn’t have a full array of mental health supports in place, said Robin Henderson, St. Charles’ chief behavioral health officer.

Deschutes County Health Services, which sees primarily Medicaid patients, has been trying to hire someone, too. Since none of the pediatric psychiatrists in Central Oregon accept the Oregon Health Plan, the state’s version of Medicaid, most of those patients are seen by the county. The county saw more than 1,100 clients under the age of 18 in the past year. When they need prescriptions, they see the county’s psychiatric nurse practitioner, an employee the county is lucky to have, Flesh said.

“The volume is high and the demand is so high that there is concern about burning the few that we have out,” he said.

Unfortunately for the county, a public salary doesn’t come close to what providers could make in private practice, Flesh said.

The shortage of pediatric psychiatrists is often held up as the most critical outpatient service that never came to fruition. Both locally and nationally, it has shifted the burden of diagnosing and prescribing medications for mental illnesses onto pediatricians, whose education generally includes only limited training in psychiatric disorders.

Dr. Logan Clausen, a pediatrician with Central Oregon Pediatric Associates, said she’s often the first person families send their kids to when they’re showing signs of depression or anxiety. She said she’s comfortable giving those diagnoses and the appropriate prescriptions, but for more complex disorders, she refers families to a child psychiatrist, which tends to be a six- to eight-week wait.

Depending on their training, not all pediatricians are comfortable treating mental illness in kids, Clausen said.

Pediatricians across the state have flocked to a new service that lets them talk over the phone with a child psychiatrist that day to discuss cases they aren’t sure about. The service, provided by OHSU and other organizations, currently fields about five calls per day, many of those from doctors in Central Oregon, Jetmalani said. Eventually, he said the partners hope to expand the service to videoconference sessions that include both patients and their doctors.

“That can help us make some of those difficult prescribing decisions that sometimes need a little bit more support from a more experienced mental health provider who can help bridge that gap,” Clausen said.

Children in crisis

When Becky Dolf first found her daughter, Ashlea, sprawled on the bathroom floor in the middle of the night, she thought the 17-year-old was drunk.

“You know how when people are drunk they just kind of sprawl? I said, ‘Are you drunk?’ She said, ‘No, I took a whole bunch of pills,’” Dolf said.

It was January, and the pills were Vistaril, a medication Ashlea had been prescribed for anxiety.

Dolf rushed her daughter to the emergency room. She had been on alert since the month before, when her daughter had told her through tears, ‘I just can’t do it anymore. I just want to die.’ Dolf took her to the ER then, too, but hadn’t followed up with day treatment because it doesn’t exist in Central Oregon.

After her suicide attempt, Ashlea’s doctor said she needed inpatient psychiatric care at a hospital. Only two hospitals in Oregon have inpatient psychiatric units for children and adolescents, both in the Portland area. They’ve got a combined total of 39 beds, and they’re usually full. That means patients elsewhere in the state, including those in Central Oregon, end up waiting in their local hospitals for days or weeks before they can get a bed.

Ashlea waited two days at St. Charles Bend for a bed to open up in Portland. When one did, it was 10 p.m. An elderly couple with the transport service Dolf’s insurance company contracted with picked Ashlea up. They drove over the mountain in a blizzard, bickering and running stop signs, said Dolf, who followed them in her own vehicle and stayed at a nearby Ronald McDonald House.

“Ashlea was terrified,” she said.

St. Charles does not treat psychiatric crises in children; it can only prevent patients from harming themselves or others. When children in psychiatric crisis arrive in St. Charles’ ER, they’re assessed and given a medical exam. In most cases, they ultimately stabilize enough to go home, Henderson, of St. Charles, said. If not, staff members determine they need inpatient care and call the two hospitals in the Portland area.

St. Charles doesn’t have a specific place to put children in mental health crisis while they wait to go to Portland, Henderson said. If the pediatric unit is full, they’ll stay in the emergency room. Sometimes they stay in the adult psychiatric emergency unit.

“We make the best decisions we can in the moment given the situation we’re dealing with in the hospital,” Henderson said.

Although older kids are sometimes placed in adult psychiatric emergency units while awaiting transport, those tend not to be good environments for kids, as adults with psychosis or intoxication can be further traumatizing, Fritz said.

Further complicating things for Central Oregon families is a 1986 federal law that requires emergency departments to treat any patient who asks for help, regardless of his or her ability to pay. The law is designed to prevent hospitals from rejecting patients or dumping them elsewhere, but it’s also forced health systems with several hospitals to give priority to patients who are already in their emergency rooms.

At the Providence Willamette Falls Medical Center in Oregon City, which runs one of the state’s two psychiatric units for kids, that means patients who are already admitted to a Providence emergency room will be the first ones admitted to Providence’s psychiatric unit for kids, said Ken Ensroth, medical director for child and adolescent psychiatry for Providence in Oregon.

The federal law makes it so that children in Portland emergency rooms get priority over those in Central Oregon, Osborn said. That forces families to make a judgment call, he said: Should they wait it out at St. Charles, where they won’t get psychiatric care, or, if it’s safe, drive their child to an ER in Portland where they’ll have a better chance of being admitted to acute care?

While Ensroth said he always recommends families take their children to the nearest ER for safety, he can understand why some would take their kids in crisis to Portland.

Dr. Shawn Crombie, the medical director of Randall Children’s Hospital Psychiatry, the state’s other psychiatric unit for kids, located within Randall Children’s Hospital at Legacy Emanuel, said his unit decides who gets beds first by using a formula to determine patients’ urgency. The top indicators, for example, are active, stated suicide intention, visible or confirmed suicidal behaviors and agitation such as yelling or posturing, he said.

That said, Crombie admitted it is “very difficult” determine who is the sickest over the phone.

Osborn is skeptical that system works, as he said it’s more about using the right words than the patients’ actual symptoms.

Even though there’s nowhere else for their kids to go, some parents say few things are harder than sending them to Portland.

The psychiatrist seeing Mountz’s daughter, Osborn, spent the entire summer urging Mountz to take her daughter to one of the psychiatric units. Initially, she resisted, unable to bear the thought of her daughter being so far away. In the months following the Mother’s Day episode, her daughter spiraled into more talk of suicide, threats of hurting family members and cutting.

Finally, in September 2012, Mountz realized she could not longer keep her daughter safe and sent her to the acute psychiatric unit for kids at Providence in Portland, which has since relocated to Oregon City.

“It was really difficult,” Mountz said. “I felt like I was failing her somehow by sending her so far away to Portland.”

Dolf’s daughter, Ashlea, who declined to be interviewed, has improved dramatically since her suicide attempt. She’s working, saving up to buy a car and thinking about college.

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While her kids were growing up, Dolf’s son, Cody, was the one who struggled. Since he was 9, he talked back to teachers and got in fights with the other kids at school. At 12, a doctor diagnosed him as having high-functioning autism, bipolar disorder and attention deficit hyperactivity disorder. Dolf struggled to find a psychiatrist to work with her son to identify the cocktail of medications that would keep him stable. In the meantime, they worked with his primary care physician and a nurse practitioner, but the medications made Cody even worse.

“One med, it made me go crazy,” said Cody Dolf, now 16. “I almost literally choked someone to death because they put me on it.”

Cody has stayed in sub-acute facilities three times, including Children’s Farm Home in Corvallis and the Parry Center in Portland.

After Ashlea’s suicide attempt, Cody said he was angry at her. He hadn’t told her before, but he had thought several times about killing himself. He ultimately didn’t because he didn’t want to hurt his family, he said.

“What helps me when I think of that is I just answer questions in my head and say, ‘Who would miss me?’ My mom would; everyone would,” Cody Dolf said, “and then I just don’t do it.”

Plus, Cody Dolf said he’s doing better now. He’s in school, and he’s starting a program that helps people with disabilities learn job skills.

“My life is actually back on track,” he said. “But when I was younger, I didn’t even care about my life. It was just torture.”

Developing solutions

Central Oregon’s health care leaders — including St. Charles, Deschutes County, Medicaid leaders and others — are working together to perform a massive assessment of how kids experiencing mental health crises are cared for. The idea is to pinpoint what new services the region needs to allow families to avoid the current options: emergency rooms or hospital beds in Portland.

While some families insist Central Oregon needs its own inpatient psychiatric unit for kids, many others, like Robinson of St. Charles, say the region doesn’t have enough patients to support its own unit, which would require 24/7 staffing and be very expensive to operate.

“We have a very severe pediatric mental health crisis, don’t get me wrong,” she said. “But going to an inpatient unit as a solution is not necessarily the best solution for our community.”

The traditional mindset for treating mental health crises involves sending kids to hospitals or residential facilities, but Robinson said she thinks the best solution would involve supporting kids in their own environments — whether that be their homes, schools or elsewhere.

“Wrapping services around the child where they are leads to better outcomes and better success,” she said.

Not only that, Crombie, who heads Randall Children’s inpatient unit, emphasized that despite the fact that his unit’s beds are almost always full, insurance reimbursement for the care tends to be low. He estimates the average inpatient psychiatric bed loses a hospital $70,000 per year.

“It’s hard to imagine a full unit all year losing that amount of money, but that’s what happens,” he said.

Other health care leaders agreed a hospital unit isn’t what Central Oregon needs — but were quick to add the caveat that something substantial would need to be built in its place to meet the unmet need.

Community leaders, aided by a consultant who’s interviewing doctors, therapists and families, are exploring several ideas that could help kids in crisis.

One strategy could be having 24/7 on-call psychiatrists and other providers who would work with kids in their homes, or commit to next-day appointments for kids in crisis. Jetmalani, of OHSU, emphasized that sometimes simply having that connection with a provider calms people down.

Other possibilities include opening entirely new mental health facilities, one option being a day treatment center where kids would receive therapy during the day and go home at night. There could also be a residential facility where they could stay for days or weeks at a time when their needs get severe.

In addition to the 39 acute hospital beds in the state, there are another 38 beds that are considered sub-acute, which refers to a free-standing facility that provides 24/7 nursing support, but children do not see a psychiatrist daily, as they would in acute care. Another 200 beds are spread across the state in residential facilities, where kids can stay for longer periods of times, as well as in day treatment facilities. None of those beds, however, are in Central Oregon, forcing the children who need them to spend time away from their families and communities.

Some families have stressed the need for so-called “respite” facilities that would simply provide a place for troubled kids to go to give their families time to decompress and take care of their own needs.

Yet another service — one that several families interviewed emphasized — would simply be support and guidance from families who have been in similar situations.

Valerie Grindstaff, whose 16-year-old stepson has spent time in a residential facility, mental health camp and counseling for depression, anxiety, a sensory disorder and reactive attachment disorder, said what ultimately helped her the most was meeting other parents who understood what she was going through.

“You want to know that you’re not alone,” said Grindstaff, who lives in Redmond. “When you’re not going out making friends, when you can’t hang out with other families, when you feel isolated because people judge you because you can’t make your child behave, that’s so isolating.”

Underlying each potential solution is the need for more child and adolescent psychiatrists — a dearth community leaders have for years tried unsuccessfully to fill.

The desperate search for solutions is happening on a state level, too. In the fall, state officials held a series of high-level meetings designed to pinpoint potential solutions to the struggles families face in trying to get intensive mental health services for their kids.

Amy Baker, who manages the child and adolescent mental health unit of the state’s Addictions and Mental Health Services, wrote in an email that the group of state health care leaders, which has been gathering input from families, hospitals, Medicaid groups and mental health providers, hopes to launch a project this winter that will test out a new strategy for connecting kids with local crisis services rather than going to emergency rooms.

Ultimately, Henderson stressed that the final plan will employ a number of solutions.

“There’s no one big, ‘Oh this is it,’” she said. “There’s got to be a number of solutions, because there is just a number of different ways to handle this problem.”

‘A hole in the system’

The troubling behavior started when Grindstaff’s stepson was only about a year and a half old, which was around the time she married his father. (They’re now divorcing.) The boy, Damon Grindstaff, would throw tantrums for hours. He screamed all of the time and refused to follow directions. None of his providers could seem to pinpoint a diagnosis. Meanwhile, the couple tried medication after medication.

“I think we were grasping for straws because we were just really struggling,” she said. “He was getting more violent at home.”

Several counselors refused to see her stepson, saying there was nothing they could do for him. Eventually, his behaviors escalated to threats to Grindstaff and her family. After several behavioral programs in his schools, Grindstaff and her then-husband sent their then-10-year-old son to a residential facility outside of Eugene called Jasper Mountain.

Through all of this, Grindstaff, at the time a teacher in the Redmond School District who received insurance through her work, was frustrated that her son didn’t qualify for the Oregon Health Plan, the state’s version of Medicaid, because she and her husband made too much money.

The state mandates that counties in Oregon provide what’s referred to as “wraparound” services for some kids who rely on OHP, and provides some of the funding for them to do so. Wraparound is an intensive treatment program in which the county staff members create teams of people to work with each child — counselors, psychiatrists, family members, neighbors, teachers, pastors — whoever is closest to him or her. The team holds regular meetings to discuss the child’s care.

Deschutes County has offered wraparound services to its OHP clients since 2004, Flesh said. The teams work to ensure the family has all the support it needs to care for the child and they try to understand what strategies would be the most effective, he said. For example, if a child has a hard time getting up in the morning, he said the wraparound team might try to decide what skills the parents need that would be useful at 6:30 a.m.

“It’s really this core group of people who wrap around the child and provide the mental health services and any ancillary ones, including education,” Flesh said.

To many families, including Grindstaff’s, that level of care sounded like just what she needed. Unfortunately for them, it’s only for OHP beneficiaries. Like many families, Grindstaff found hers in a gap in which she and her husband didn’t make enough money to afford $180-per-hour intensive services but too much to qualify for OHP.

“We were right in the middle,” she said.

Now, when Grindstaff talks about reforming the mental health system, she emphasizes the need for more services that can be available to middle-class families, many of which can’t afford expensive, high-level care, but are not poor enough to qualify for OHP.

“It’s such a hole in the system,” she said.

Jetmalani, of OHSU, agrees. While he pointed out that the state has made major investments to ramp up the availability of wraparound services for OHP, he says that leaves out many families who don’t qualify but would still benefit from that level of care.

“Commercial insurance is actually a barrier to a lot of getting the highest level of treatment,” he said. “It’s actually easier to access a lot of intensive services with Medicaid than with not having Medicaid, which is ironic.”

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Grindstaff — who finally was able to enroll her stepson in OHP following mediation — said her struggle to get services for her stepson inspired her to quit her job as a schoolteacher and start a business designed to help families like hers. She and an old friend, Shannon Pugerude, whose 14-year-old daughter has been diagnosed with psychosis — launched Wyldwoodz Resource Center last summer. There, the two women train parents, caregivers, teachers and others to support kids with mental health and behavioral issues and develop educational curricula to help them.

Neither Grindstaff nor Pugerude are psychiatrists, but Pugerude is trained in a counseling strategy she has found helpful with her daughter: collaborative problem-solving. Developed at Massachusetts General Hospital, the approach is rooted in the idea that behavioral challenges in children are prompted by lagging thinking skills, and can be overcome by simply teaching kids the skills they lack. Rather than parents imposing their wishes onto children, as most tend to — think ‘Feed the dog’ or ‘Be quiet’ — collaborative problem-solving involves understanding the child’s concern, letting him or her know the adult’s wishes won’t be imposed and then inviting the child to brainstorm solutions with the adult.

The strategy is the basis for everything they do at Wyldwoodz, Pugerude said.

‘We’re in some trouble’

Mountz originally had planned to adopt from Ukraine. She had all of the paperwork ready until, tooling around on adoption forums online, she came across a captivating pair of headshots. Two young girls. Biological sisters, ages 7 and 8.

The younger of the two looked happy and healthy, with rosy cheeks and a wide smile.

The older one was much smaller. She was very pale, and most of her hair had been chopped off. But it was her facial expression that struck Mountz the most. She looked frightened.

“She just looked like a scared little puppy,” Mountz said. “Her face looked like she was very uncomfortable.”

The younger daughter has done well in school and hasn’t showed any signs of mental distress. But the older one, now a junior in high school, has been in and out of residential facilities and hospital wards. After her first stint in the psychiatric unit in Portland, the staff sent her to a facility in Corvallis called Children’s Farm Home. Two weeks after that, a staff member called Mountz and told her they couldn’t handle her daughter any longer. At the time, she was telling the staff daily she wanted to kill herself. Staff members told Mountz they were taking her daughter to the emergency room in Portland, which is where she met them and stayed overnight. The next stop was Youth Villages, another residential treatment facility in Lake Oswego, where she stayed from December 2012 to April 2013.

When she was stable enough to be released, the staff recommended she enter a day treatment facility, but since there is none in Central Oregon, Mountz worked with the school district to carefully design a school schedule that kept her separate as much as possible from the other kids, who had been spreading brutal rumors in her absence.

Now, Mountz said, her daughter still struggles, but she’s nowhere near where she once was.

“She’s not the kid who Children’s Farm Home said she was,” Mountz said. “They said she was the worst of the worst and she just really needed to be in a facility probably forever.”

A doctor eventually diagnosed Mountz’s daughter with post-traumatic stress disorder and major depressive disorder.

Mountz said she’s tried to ask her daughter what happened to her back in Russia, but it’s not clear.

Research has shown that traumatic experiences during early childhood are at the root of many mental and physical health problems in adults because they affect the neural pathways in the developing brain, which can have long-lasting effects. The largest study on the subject to date, the Adverse Childhood Experiences study, started in 1995. It’s following 17,000 adults who answered questions about mistreatment and family dysfunction during childhood and about their current struggles with mental illness or substance abuse disorders and found significant correlation between negative childhood experiences and poor health outcomes later in life.

“It was quite linear,” Jetmalani said. “The more traumatic experiences you’ve had, you were essentially destined to have obesity, diabetes, lung disease.”

That’s all the more reason to emphasize prevention and outpatient mental health services, so that issues in children are addressed before becoming full-blown crises, Jetmalani said.

At Central Oregon Pediatric Associates, licensed psychologist Sondra Marshall works as a behavioral consultant, meaning she works to help patients — roughly 40 percent of whom are seeing pediatricians for mental health concerns — resolve mental health issues, especially those that manifest as physical issues like abdominal pain or constipation. She said work is being done to try to get health insurers to cover behavioral health visits in the same way as physical health, which would catch kids at risk of serious mental health issues early on. Because in reality, many of the children who ultimately commit suicide are not the ones who spent time in emergency rooms or psychiatric units, Marshall said. They’re not the “in-your-face” kids; they’re the ones who slip by unnoticed, she said.

“What can we do earlier so that we can really, hopefully, identify these kids that aren’t the real externalizers,” she said. “They’re the internalizers, and they’re the kids that are hurting themselves too. That we’ve lost.”

Until that happens, things could get worse. Oregon — and especially Central Oregon — has seen a jump in suicides as of late. At least five teens died by suicide so far in Deschutes County through August, according to data from the Oregon Health Authority. That represents a significant increase from previous years. Since 2003, the county has seen an average of one adolescent suicide per year, and never more than three in a year, according to the OHA.

Winter is always the toughest time of the year for people struggling with mental health issues, and this one could be a particularly hard one, Jetmalani said. While he said he’s hopeful that all of the attention on the issue could improve things in the next three to five years, it will get worse before it gets better.

“I’m very worried about the short term,” Jetlamani said. “Right now, we’re in some trouble.” •